HUMAN FACTORS

Human Factors Training

Program
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 HUMAN FACTORS INTRODUCTION

What is Human Factor?

"Human factors is the study of the human as a

central part of any system.
Human factors identify the capabilities and
limitations of humans and then adapt the human
or the system components accordingly.

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HUMAN FACTORS INTRODUCTION

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HUMAN FACTORS INTRODUCTION

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HUMAN FACTORS TRAINING PROGRAM

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Human Factors Training Program

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Human Factors Training Program

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 HUMAN FACTORS TRAINING-WHY ?
 TO INCULCATE A POSITIVE AIRLINE SAFETY
CULTURE

 IDENTIFY METHODS TO RECOGNIZE ,UNDERSTAND

AND MANAGE HUMAN PERFORMANCE ISSUES

 TO IMPROVE WORK PERFORMANCE AND ALSO

PROMOTE WORKFORCE PHYSICAL AND
PSYCHOLOGICAL HEALTH.

 AWARENESS OF HUMAN FACTOR ISSUES THAT

AFFECT JOB PERFORMANCE THROUGH INTIAL AND
RECURRENT TRAININGS
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 ERRORS IN MAINTENANCE
Types of Error in Maintenance Task
Errors during Regular and Less Frequent Maintenance
Tasks
 A large proportion of maintenance tasks are fairly
routine, such as regular, periodic checks on aircraft.
Thus, engineers will use a certain set of procedures
relatively frequently and slips and lapses can occur
when carrying out procedures in the busy hangar or
line environment.

 Relatively frequently and slips and lapses can occur

when carrying out procedures in the busy hangar or
line environment.

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 ERRORS IN MAINTENANCE
 In the "Repetitive Tasks", engineers will often-
become so accustomed to doing a regular, often
repeated task, that they will dispense with written
guidance altogether.

 It would be unrealistic and unnecessarily time

consuming to expect them to constantly refer to
familiar guidance material. However, errors may
occur if they do not keep up-to-date with any changes
that occur to these frequently used procedures.

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 ERRORS IN MAINTENANCE

 These routine tasks are also prone to complacency,

environmental capture and rule-based errors.

 When undertaking less frequently performed tasks,

there is the possibility of errors of judgment. If the
engineer does not familiarize or familiarize himself
properly with what needs to be done, he may
mistakenly select the wrong procedure or parts.

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 ERRORS IN MAINTENANCE

Avoiding and Managing Errors

 Whilst the aircraft maintenance engineering industry

should always strive towards ensuring that errors do
not occur in the first place.

 It will never be possible to eradicate them totally.

Therefore all maintenance organizations should aim
to ―manage‖ errors.

 Prevent errors from occurring and Eliminate or

mitigate the bad effects of errors

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 ERROR MANAGEMENT

One of the things likely to be most effective in

preventing errors is to make sure that engineers follow
procedures.

This can be effected by ensuring that the means of

presentation of the information is user-friendly and
appropriate to the task and context, that engineers are
encouraged to follow procedures and not to cut corners.

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 ERROR MANAGEMENT
PERSONAL MINIMUM CHECKLISTS

Before the Task

• Do I have the knowledge required to perform the task?

• Do I have the technical data required to perform the task?
• Have I performed the task before?
• Do I have the proper tools and equipment required to perform the task?
• Have I had the proper training required to support the job task?
• Am I mentally prepared to perform the job task?
• Am I physically prepared to perform the job task?
• Have I taken the proper safety precautions to perform the task?
• Do I have the required resources available to perform the tasks?
• Have I researched the Civil Aviation Requirements (CARs), Airworthiness
Directives (AD), Service Bulletins (SB) and other important documents to
ensure compliance?

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 ERROR MANAGEMENT
After the Task
• Did I perform the task to the best of my abilities?
• Is the result of the job task performed equal to or better than the original
design?
• Was the job task performed in accordance with appropriate data?
• Did I use all the methods, techniques, and practices acceptable to the
industry?
• Did I perform the job task without pressure, stress and distractions?
• Did I re-inspect my work or have someone inspect my work before
returning the aircraft to service?
• Have the required "Independent Checks" of affected controls been
accomplished and recorded?
• Did I record the proper entries for the work performed?
• Did I perform the operational checks after the work was completed?
• Am I willing to sign off for the work performed?
• Am I willing to fly in the aircraft once it is approved for the return to
service?
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 PERFORMANCE AND LIMITATIONS

Human Performance and Limitations

⚫ Vision
⚫ Hearing
⚫ Attention and Perception
⚫ Situational Awareness
⚫ Memory
⚫ Claustrophobia, Physical Access and Fear of Heights
⚫ Motivation
⚫ Stress
⚫ Sleep
⚫ Fatigue
⚫ Alcohol, medication and drugs
⚫ Physical Work
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 PROFESSIONALISM AND INTEGRITY

PROCEDURES, PRACTICES, PROFESSIONALISM

AND INTEGRITY

Visual Inspection

There are various steps that an engineer can take to help

him carry out a reliable visual inspection.
The engineer should:
⋅ Ensure that he understands the area, component or
system he has been asked to inspect (e.g. as specified
on the work Card);

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 PROFESSIONALISM AND INTEGRITY

• Locate the corresponding area, component or system

on the aircraft itself:
• Make sure the environment is conducive to the visual
inspection task (considering factors such as lighting,
access, etc.);
• Conduct a systematic visual search, moving his eyes
carefully in a set pattern so that all parts are
inspected:
• Examine thoroughly any potential degradation or
defect that is seen and decide whether it constitutes
a problem.

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 GOOD MAINTENANCE PRACTICE
Work Logging and Recording
This is one of the most critical aspects of
communication within aviation maintenance, since
inadequate logging or recording of work has been cited
as a contributor to several incidents.

Even if engineers think that they are going to complete

a job, it is always necessary to keep the record of work
up-to-date just in case the job has to be handed over.
This may not necessarily be as a result of a shift
change, but might be due to a rest break, illness, the
need to move to another (possibly more urgent) task,
etcIMAGE

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 ERROR IN MAINTENANCE

Basic rules of thumb to help aircraft maintenance

engineers minimize poor communication are:

 Think about what you want to say before speaking or

writing;
 Speak or write clearly;
 Listen or read carefully;
 Seek clarification wherever necessary

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 AWARENESS

Keeping Up-to-Date, Currency

To maintain the currency, he must keep abreast

of pertinent information relating to:

 New aircraft types or variants;

 New technologies and new aircraft systems;
 New tools and maintenance practices;
 Modifications to current aircraft and systems he works
on;
 Revised maintenance procedures and practices.

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 AWARENESS
Engineers are likely to keep up-to-date by:
• Undertaking update courses;
• Reading briefing material, memos and bulletins;
• Studying maintenance manual amendments
• Responsibility for maintaining currency lies with both
the individual engineer and the maintenance
organization for which he works. The engineer should
make it his business to keep up-to-date with changes
in his profession (remembering that making
assumptions can be dangerous).

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 FACTORS AFFECTING PERFORMANCE
 “THE DIRTY DOZEN”

. 1. Lack of communication 7. Lack of parts

2. Complacency 8. Pressure

3. Lack of knowledge 9. Lack of assertiveness

4. Distraction 10. Stress

5. Lack of teamwork 11. Lack of awareness

6. Fatigue 12. Norms

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 DIRTY DOZEN-COMMUNICATION

The Dirty Dozen:

1. Lack of communication

 Use logbooks, worksheets, etc. to communicate and

remove doubt.

 Discuss work to be done or what has been completed.

 Never assume anything

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DIRTY DOZEN-COMMUNICATION

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 DIRTY DOZEN -COMPLACENCY

• Satisfaction with a situation to the extent that a

degradation of vigilance occurs.

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 DIRTY DOZEN-COMPLACENCY

2. Complacency
 Train yourself to expect to find a fault.
 Never sign for anything you didn't do [or see done]. ―If
something can go wrong, it will-MURPHY LAW

3. Lack of knowledge

 Get training on type aircraft.

 Use up-to-date manuals.
 Ask a technical representative or someone who
knows

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 DIRTY DOZEN-DISTRACTION

4. Distraction
 Always finish the job or unfasten the connection, Mark the
uncompleted work.
 Lock wire where possible.
 Double inspect by another or self.
 When you return to the job, always go back three steps.
 Use a detailed check sheet.

5. Lack of teamwork
 Discuss what, who and how a job is to be done.
 Be sure that everyone understands and agrees

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 DIRTY DOZEN-FATIGUE
6. Fatigue
 Be aware of the symptoms and look for them in yourself
and others.
 Plan to avoid complex tasks at the bottom of your circadian
rhythm.
 Sleep and exercise regularly.
 Ask others to check your work. IMAGE

7. Lack of Resources
 Check suspect are as at the beginning of the inspection
and AOG the required parts.
 Order and stock anticipated parts before they are required.
 Know all available parts sources and arrange for pooling or
loaning.
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 DIRTY DOZEN-PRESSURE,STRESS

8. Pressure
 Be sure the pressure isn't self-induced.
 Communicate your concerns.
 Ask for extra help.
 Just say 'No'.

9. Lack of assertiveness
 If it's not critical, record it in the journey log book and
only sign for what is serviceable.
 Refuse to compromise your standards.

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 STRESS

10. Stress

 Be aware of how stress can affect your work.

 Stop and look rationally at the problem.
 Determine a rational course of action and follow it.
 Take time off or at least have a short break.
 Discuss it with someone.
 Ask fellow workers to monitor your work.

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 DIRTY DOZEN-LACK OF AWARENESS,NORMS

11. Lack of awareness

 Think of what may occur in event of an accident.
 Check to see if your work will conflict with an existing
modification or repair.
 Ask others if they can see any problem with the work
done.
12. Norms
 Always work as per the instructions of have the
instruction changed.
 Be aware the "norms" don't make it right

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 CONCLUSION

A COMBINATION OF TECHNICAL SKILLS AND

UNDERSTANDING OF HUMAN FACTORS WILL

GUARANTEE:

 IMPRVOVED FLIGHT SAFETY

 LESS PERSONAL INJURY

 BETTER AIRCRAFT AVAILABILITY AND ECONOMICS BENEFITS

 HIGHER MOTIVATION AND JOB SATISFACTION

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CONCLUSION

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 Jet Serve
Aviation
Presentation
on
SMS
JSA Flight Safety Team
Safety Management System (SMS)
Evolution of Aviation Safety
(Organizational Era)

WORLWIDE ACCIDENT RATES

Source: 1001crash.com
Safety Management System (SMS)

Evolution of Aviation Safety

Three Eras:
• Technical Era
• Human Era
• Or g an iz a tio n a l E ra
TE C H N I C A L
ERA
(1903 to late
HUMAN ERA
1960s)

TODA
(1970s to mid

Y
1990s) ORGANIZATIONAL
ERA
(1990s to present)
1950s 1970s 1990s 2000s
Safety Management System (SMS)

A Safety Management System is a businesslike approach to safety. Common with

all management systems a safety management system provides for goal setting,
planning, and measuring performance. It concerns itself with organizational safety
rather than the conventional health and safety at work.

Four SMS Functional Components

• Safety Policy
• Safety Risk Management
• Safety Assurance
• Safety Promotion
Safety Management System (SMS)
Safety Accountabilities:
• Accountable Executive
• Senior Management
• All Managers / Safety Officers
• All Employees

SMS Key Safety Personnel:

• Safety Manager (Chief of Flight Safety)
• Airline Safety Committee
• Safety Action Group (SAG)
• Local Safety Action Group (LSAG)
Safety Management System (SMS)

IndiGo Safety Policy

Continuous
Establishes IndiGo senior management's Improvement
commitment to continually improve Policy
safety; defines the methods, processes, Mgt. policy
and organizational structure needed to
meet safety goals.
Process
Revised IndiGo Safety Policy based on Safety
Task
SMS issued by president on 30th Jan 12.

IndiGo Safety Policy- available at IndiGo

Portal also is displayed in all IndiGo Offices.
Systematic
Safety Management System (SMS)

Safety Risk Management (SRM)

Determines the need for, and adequacy of, new or revised
risk controls based on the assessment of acceptable risk.

A formal process within the IndiGo SMS

composed is of:
• System Description
• Identifying the hazards
• Assessing the risk
• Analyzing the risk
• Controlling the risk
Safety Management System (SMS)
Safety Risk Management (SRM) (Cont’d…)

Hazard is a condition or an object with the potential to cause injuries to

personnel, damage to equipment or structures, loss of material or
reduction of ability to perform a prescribed function.

Hazard Identification at IndiGo:

• Predictive Process

• Proactive Process

• Reactive Process
 Hazard:
Condition, Accident:
Object or Unforeseen
Activity With a and
Potential Risk Unplanned
Factor!! Event or
Circumstance
In!c!ident:
Unforeseen
Risk: event that
Consequence of can lead to
a Hazard an accident!!
Measured in
terms of
Likelihood and
Severity!!
A Hazard Reported Today = An Accident Prevented Tomorrow
https://6eworld.goindigo.in/flightsafe/default.aspx
 Mandatory V/s Voluntary Reports by
Pilots

 All Incidents as per Air Safety Circulars 5/82 , needs to be

reported. Mandatory reporting like :

• RA

• EGPWS

• Unruly Passengers

• Death on Board

 Other Hazards should be reported in Hazard Reports, Voluntary

reports or Anonymous Voluntary reports under FSF-09 or FSF-08.
 Safety Management System (SMS)
Safety Risk Management (SRM) (Cont’d…)
Reporting of Hazards
Why?
• To identify trends in incidents and ill-health
• To identify underlying causes
• To identify the need to review / improve SMS
Who?
• Safety Manager (Chief of Flight Safety) / Safety Cell.
fltsafe.hq@goindigo.in / dhruv.rebbapragada@goindigo.in
How?
• Anonymous / Voluntary Report Form
• Hazard Report
• Other Flight Safety Forms
All above mentioned forms are available at IndiGo Web Portal / Airport Manager Office / In aircraft, E
 Safety Management System (SMS)
Safety Risk Management (SRM) (Cont’d…)
Analyzing of Hazards & Risk Management
• Risk assessment – Risks are assessed in terms of
– Consequence
– Likely hood

• Risk Control Methods-

– revision of the system design

– modification of operational procedures

–establishment of contingency arrangements

Risk Assessment

Risks are assessed in terms of

• Risk Probability
• Risk Severity

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Risk Probability

The likelihood that an unsafe event or condition

might occur

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Risk Severity

The possible consequences of an unsafe event or

condition

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Risk Matrix

Graphical tool that combines:

– Risk Probability
– Risk Severity

Put the two together as:

Risk = Likelihood * Severity

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Risk Matrix

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Risk Index
The composite of probability and severity is the risk
index of the consequences of the hazard

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Risk Tolerability
Describes the Tolerability criteria

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Hazard Log

 Effective documentation is a cornerstone of effective

SMS
 Formal repository of safety knowledge
 Historical safety knowledge will enables to make
safety decisions based upon facts and not opinions

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Hazard Log

S. Risk
Risk Name Hazard Source Scope of Risk
No No

As per ATC "TWY F" is

compatible for airbus &
Damage to
FLT- sharklets 35.8m but "TWY F"
Taxing Hazard aircraft,
1 2014 appears less than 25m ,
issues Report airport
-001 reduced maneuverability &
structure
close proximity of Bunkers may
constitute hazard

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Hazard Log

Stake
Risk Risk
Place Risk Type Holder Owner Risk Severity
Probability Control
s

Flight
XXX Operational xxxxx Hazardous Remote 5
Ops

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Hazard Log

Residual Additiona
Control Risk Risk level Accepted Residual Risk
Risk l Risk
Description Level accepted by Consequence Likelihood Control

Charts,
Extremely
Informatio
Medium No Major improbabl 4
n to Flt
e
crew

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Hazard Log

Residual
Residual Accepted Action to
Additional Control Description Risk level
Risk Level by be taken
accepted
Following are the responses
from SATCO Chandigarh: (Point
1,2,3,4)
1. Taxiway “F” width and the
Taxiway joining ORP RWY29
and TWY “F” is 50 ft.
To be
2. Area is properly marked and
reviewed
lighted to guide the Aircraft
Safety during
maneuver . Low Yes
Manager next
3. The Blast Pens are cleared of
Safety
maneuvering area and distance
Inspection
to the nearest Blast Pen is 120.
5 ft.
4. The area meets the 60
requirement of below planning
Hazard Log
Date
Date Due Review Review
added to Remarks
identified by date By
Register

Mail reflects that Crew can be

advised that TWY”F” and the
xxxxxxx xxxxxx NA NA
adjacent area can be used by
Category “C: Aircraft

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Hazard Log
Mail sent to
Next Close Reported Reminde
Date closed O/C the
Review by by r
Reporter

Close
NA xxxxx xxxxxx Flight Ops NA YES
d

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Safety Management System (SMS)

Safety Assurance (SA)

Evaluates the continued effectiveness of implemented risk control
strategies; supports the identification of new hazards.
Why?
• Ensure outputs meet or exceed
IndiGo safety requirements
• Ensures regulatory compliance
How?
• Information Acquisition
(Audits ,Employee reporting ,etc)
• Data Analysis
• System Assessment
Safety Management System (SMS)
Safety Assurance (SA) Cont’d…

Safety Objectives:
The Safety Objectives are the driving force required to achieve the standards
laid down in the IndiGo Safety Policy.

Safety Performance Measurement:

• Safety Performance Targets

• Safety Performance Indicators
Safety Management System (SMS)

Safety Promotion —
 SMS training

 Positive safety culture

 Safety communication and awareness

Everyone has a role in promoting safety

Safety Is Everybody’s Concern.
Report all injuries, equipment
damage and near-collisions
to Flight Safety

Thank You